CODING & DOCUMENTATION
Fam Pract Manag. 2017 Jan-Feb;24(1):35.
Author disclosure: no relevant financial affiliations disclosed.
How many vital signs must we document to count the constitutional system as an exam element when determining the level of an evaluation and management (E/M) service, according to Medicare's documentation guidelines?
If you are using the 1995 documentation guidelines, you need only one vital sign. However, if you are using the 1997 guidelines, any three vital signs will count as one bullet in the constitutional system. The seven vital signs are sitting or standing blood pressure, supine blood pressure, pulse rate and regularity, respiration, temperature, height, and weight. General appearance is also an element of the constitutional system. Ancillary staff may measure and record vital signs.
When determining the level of an E/M service, should I include family history as noncontributory or unremarkable in assessing the level of service?
The majority of Medicare administrative contractors (MACs) and some private payers have stated that “noncontributory” is not sufficient for documentation of the family history.
However, Novitas Solutions (a MAC) noted, “The use of the term ‘noncontributory’ may be permissible documentation when referring to the remaining negative review of systems. The term ‘noncontributory’ may also be appropriate documentation when referring to a patient's family history during an E/M visit, if the family history is not pertinent to the presenting problem.”
Remember that for established patients, when you make no changes to the family history obtained at prior encounters, it is sufficient to document that fact (e.g., family history – reviewed, no change from 10/01/2015).
What ICD-10 codes should we report for a preoperative exam?
The first ICD-10 code listed for a preoperative exam is typically Z01.818, “Encounter for other preprocedural examination.” List secondary codes to describe the
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